Medical Policy

Subject:

Standing Frames

Policy #:

DME.00034

Current Effective Date:

01/13/2015

Status:

Reviewed

Last Review Date:

11/13/2014

Description/Scope

This document addresses the use of standing frames, which are assistive devices that provide an alternative position for individuals confined to supine, prone, or sitting positions. These devices allow the individual to achieve a standing position and then support the person in the standing position. Standers can be integrated to use with wheelchairs for those in a sitting position. Other types of standing frames are designed for those in a prone or supine position to achieve a standing position.

Position Statement

Investigational and Not Medically Necessary:

Standing frames are considered investigational and not medically necessary for all indications.

Rationale

The published studies that address passive standing for individuals with neurological mobility disabilities, (for example, cerebral palsy, spinal cord injuries, and stroke) do not have consistent outcomes. The theory that passive standing enhances hip alignment, bone mineralization, urinary function, respiratory functioning and psychosocial functioning has not been proven in appropriately designed research studies.

Bagley and colleagues (2005) conducted a randomized controlled trial (RCT) of 170 individuals in an inpatient stroke rehabilitation unit. The participants had a clinical diagnosis of stroke, were medically stable and unable to achieve any score on the Trunk Control Test or unable to stand in mid-line without the assistance of two therapists. Two groups, an intervention group (n=71) and control group (n=69), received usual stroke unit care but the intervention group also received a minimum of 14 consecutive days of treatment using the standing frame. The primary outcome measure was the Rivermead Mobility Index (RMI). Blinded participant assessments were undertaken at baseline, 6 weeks, 12 weeks, and 6 months post stroke. There was no statistically significant difference between groups in any of the outcome measures or for resource use. Mann-Whitney U-tests for the RMI change from baseline scores to 6 weeks, 12 weeks and 6 months post stroke were p=0.310; p=0.970 and p=0.282, respectively.

Allison and colleague (2007) studied 17 post stroke individuals in a rehabilitation unit. Each participant was randomly allocated into a control group (who received conventional physiotherapy) or a treatment group (who received conventional therapy plus an additional session of standing practice). The period of intervention ranged from 14 to 28 days depending on the individual's length of stay on the unit. The Gross Functional Tool Section of the Rivermead Motor Assessment, the Trunk Control Test and the Berg Balance Scale were used on admission to the study, at weekly intervals during the intervention, and at 12 weeks after discharge. Of the 17 participants recruited, 3 withdrew from the additional intervention group citing fatigue as a barrier and 15 completed the study. Participants who completed additional standing practice demonstrated higher scores in all motor measures at week 12, but this difference was not statistically significant. There was a statistically significant difference (p<0.05) in the changes in Berg Balance score when comparing week 1 with week 12 for the group receiving extra standing practice. The authors concluded that a larger study is required to establish the value of additional standing practice after stroke. This pilot demonstrates that the Gross Functional Tool Section of the Rivermead Motor Assessment and the Berg Balance Scale would be useful in such a study.

Caulton and colleagues (2004) studied severely disabled children with cerebral palsy (CP) to determine whether participation in 50% longer periods of standing (in either upright or semi-prone standing frames) would lead to an increase in the vertebral and proximal tibial volumetric trabecular bone mineral density (vTBMD). Non-ambulant children with CP are prone to low trauma fractures, which are associated with reduced bone mineral density. A heterogeneous group of 26 pre-pubertal children with CP (14 boys, 12 girls; age 4.3-10.8 years) participated and were matched into pairs using baseline vertebral vTBMD standard deviation scores. Children within the pairs were randomly allocated to either intervention (50% increase in the regular standing duration) or control (no increase in the regular standing duration) groups. Pre- and post-trial vertebral and proximal tibial vTBMD was measured by quantitative computed tomography (QCT). The median standing duration was 80.5% (range, 9.5%-102%) and 140.6% (range, 108.7%-152.2%) of the baseline standing duration in the control group and intervention group respectively. The mean vertebral vTBMD in the intervention group showed an increase of 8.16 mg/cm3, representing a 6% mean increase in vertebral vTBMD. No change was observed in the mean proximal tibial vTBMD. The authors found that a longer period of standing in non-ambulant children with CP improves vertebral, but not proximal, tibial vTBMD. The authors concluded that such an intervention might reduce the risk of vertebral fractures, but is unlikely to reduce the risk of lower limb fractures in children with CP.

Gudjonsdottir and colleagues (2002) in a case series examined how two types of standers affected BMD and behavioral variables in four children of preschool age with severe CP. In phase I of the study, 2 children stood in a conventional stander and 2 stood in a new type of motorized (dynamic) stander that provided intermittent weight bearing standing for 30 minutes a day, 5 days a week for 8 weeks. In phase II, all 4 subjects stood in both types of stander during 3 separate test sessions. Measurements of BMD, before and after the program, revealed increases in BMD in both children who used a dynamic stander and 1 child who used a static stander. Measures of behavioral variables, including behavioral state, reactivity, goal direction and attention span, indicated little or no effect on behavior from use of the different types of stander. These results suggest there is potential value in additional research concerning the effects of static and dynamic standers on both BMD and behavior in children with CP.

Kecskemethy and colleagues (2008) acknowledged that despite widespread use, little is known about the actual weight borne while in a stander and the impact on BMD. They studied 6 males and 14 females in an attempt to quantify actual weight bearing while in 2 types of passive standers. The participants ranged in age from 6 to 21 years, had quadriplegic CP and were non-ambulatory. For each participant, weight bearing was monitored continuously during a routine 30-minute standing session using 1 of 2 standers. The total number of monitored sessions was 108. Right and left weight bearing was measured by the use of footplates interfaced with axial load cells. Weight borne during the 108 standing sessions ranged widely from 37% to 101%. Although mechanical loads are important for obtaining and maintaining bone mineralization, the findings of this study showed that skeletal loading is a very complex process not easily evaluated. The benefits of passive standing are dependent upon factors intrinsic to the particular person, (for example, physical status), as well as extrinsic factors, such as the device(s) used, positioning and measurements of clinical outcomes. The authors concluded that the quantity and quality of objective, scientific evidence demonstrating the benefits of weight bearing are varied and not always consistent, indicating the need for further studies to assess the benefits of weight bearing to include an assessment of actual weight borne.

Hough and colleagues (2010) systematically reviewed the published literature addressing the efficacy of interventions, (for example, medical and physical) to improve low bone mineral density (LBMD) in children and adolescents with cerebral palsy (CP). The authors found that the most promising interventions for decreased BMD were weight bearing and bisphosphonates. However, there are variations in bone development for pre- and post-pubescent individuals with CP. The cause of this variation is unknown and additional large RCTs are needed of both physical and medical approaches.

Background/Overview

A sit-to-stand device allows the individual with upper body strength to achieve a standing position from a wheelchair without assistance. A sling is slipped behind the buttocks and hooked onto the frame of the standing device. The person's legs and feet are placed in supports on the frame. By using a pneumatic pump lever, the person lifts himself/herself to a standing position. A back support is rotated in place to support the individual's back.

A prone or supine stander is positioned next to the individual, usually next to a bed. The individual is either rolled or transferred to the device with the help of a sling lift. Once positioned on the device, the person's extremities are secured and the device is changed to a vertical (standing) position.

Standing frames can be categorized by types:

Passive (static) stander: A passive stander remains in one place, sometimes has casters but cannot be self-propelled;

Mobile (dynamic) stander: User can self-propel a mobile stander if they have upper body strength to push a manual wheelchair. Some standers are also available with powered mobility;

Bone mineral density: A term used to describe the amount of calcium present in bone.

Prone: Lying with the front or face downward.

Reciprocal movement: Alternate movements of arms and legs seen in walking and other normal movements.

Rivermead Mobility Index: A measure of disability related to bodily mobility that evaluates the individual's ability to move her or his own body.

Supine: Lying on the back or having the face upward.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:

HCPCS

E0637

Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels [when specified as standing system]

E0638

Standing frame/table system, one position (e.g., upright, supine, or prone stander), any size including pediatric, with or without wheels

E0641

Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Reviewed

11/13/2014

Medical Policy & Technology Assessment Committee. No change to position statement. Rationale and References were updated.

Reviewed

11/14/2013

MPTAC review. No change to position statement. References were updated. Updated Coding section with 01/01/2014 HCPCS descriptor changes for E2301.

Reviewed

11/08/2012

MPTAC review. No change to position statement. References were updated.